Development of a Palliative Care Intervention and Clinical Pathway for Non-Surgical Management of Hip Fracture in Patients with Advanced Illness (310-C)

Abstract

1.Describe how goals-of-care discussions impact decisions regarding management of hip fractures in patients with advanced illness.2.Review the development and impact of a palliative care clinical pathway for decisional support and non-operative management of hip fracture. Background. Patients with advanced illnesses often undergo surgical hip fracture repair despite significant perioperative risk and limited chance of preserving functional status or improving life expectancy. There is a subset of patients with advanced illness and limited life expectancy who would benefit from noninvasive management when primary goal of care is comfort. There are no protocols described in the medical literature for discussing nonsurgical options, or the impact of goals-of-care discussions on decisions regarding hip fracture repair. The research on non-operative management of hip fracture is very limited. A small retrospective review of hospice patients in 2001 found that surgical repair did not significantly benefit survival or comfort. However, hip fracture repair is frequently considered in this population, for the goal of comfort, and sometimes function and longevity. Patients with end-stage dementia have a 50% 6-month mortality following hip fracture and suffer more postoperative complications than cognitively intact patients, including pain and delirium. Aim. To develop collaboration between palliative care, orthopedic surgery and hospitalists to ensure goals-of-care discussions occur when a patient with advanced illness suffers a hip fracture and that the plan of care is most consistent with goals of care. Methods/session descriptions. Guidelines for initiating a palliative care consult and a clinical pathway for nonsurgical management of hip fracture were developed and implemented. We reconciled the nuanced differentiation of surgical decisions based on perioperative risk assessment versus decisions based on goals of care. A pre- and postintervention case review was conducted to determine impact of intervention on goal setting and plan of care. Conclusion. In patients with advanced illness and hip fracture, a collaboration between palliative care physicians, orthopedic surgeons, and hospitalists can increase the likelihood of establishing appropriate goals of care and of care, with or without surgery, that are most aligned with patients’ goals. Physical Aspects of Care